PARSONS
BRINCKERHOFF
DIRECT DEPOSIT APPLICATION/CHANGE FORM
Please read Instructions on reverse side before completing entire form
EMPLOYEE INFORMATION
A.
Name Employee Number
______
(Please Print)
Work Telephone Number Work Location (Check One)
______- ______- ______o United States o Puerto Rico
o Canada (See reverse side for Bank information)
PAYMENT OPTIONS / ACCOUNT TYPE (choose one or two of the following)B.
o Initial Enrollment (complete section D)
o Change Account Number(s) and/or
Routing Number(s)
(complete section D)
o Cancel Entire Direct Deposit
/ C. All accounts must be US$ accounts located in the United States
or with US affiliated Banks (see reverse side for Canada)
Primary Secondary
o Regular Checking Account o o
(attach voided check)
o Savings Account o o
(obtain and attach letter from Bank
indicating account and routing numbers)
o Credit Union Account o o
(obtain and attach letter from Credit Union
indicating account and routing numbers)
o Money Market Account o o
(obtain and attach letter from Bank or Investment
House indicating account and routing numbers)
ENROLLMENT AND CHANGE AUTHORIZATION
D. I authorize Parsons Brinckerhoff to deposit all Payroll related payments directly into my account(s) and toinitiate debit entries (if necessary) and make adjustments to any credit entries in error to my account(s) as
indicated below.
Are you splitting your Direct Deposit? ____Yes ____No [if “no”, only enter data in “Primary “ account field]
PRIMARY Bank Routing Number /___/___/___/___/___/___/___/___/___/ ______% OR $______*
PRIMARY Account Number /___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
SECONDARY Bank Routing Number /___/___/___/___/___/___/___/___/___/
SECONDARY Account Number /___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/___/
* If net amount of payment is less than dollar amount you specified for the Primary account then all funds shall be deposited to Primary account
EMPLOYEE SIGNATURE (form must be signed and dated)
E.
SIGNATURE ______DATE______